Why Do We Fail to Follow Procedures?

Transcription

1 WELCOME to the NBAA HPN Regional June 2018 Why Do We Fail to Follow Procedures? Bob Gould Bravo Golf Aviation

2 Question? How many of you have NOT followed a prescribed procedure in an operations or maintenance manual publication in your career? How many of you have NOT followed any prescribed procedure or rules such as putting together your kid s bicycle? And WHY NOT????

3 Why should we be concerned? Failure to follow proper procedures is one of the most FAA issued violations. FAA

4 Types of Human Errors There are three basic errors we make. Execution Errors PiNC -We Procedural make an error (intentional) due to forgetting Non-Compliance to do something. (known shortcuts) We make an error because we did not follow a procedure exactly as described. Planning Errors MuNC - Managerial (understanding) Non-Compliance (requested by management for expeditious needs) We did the wrong task, but did the task correctly. Violation Errors We purposely did not follow correct procedures (shortcuts, not following checklists or procedures). Failure to follow procedures.

5 Why Do Good Employees Violate Procedures? Most Potential Producing Errors The Famous Eight 1. Excessive Reliance on Memory 2. Interruptions 3. Self-Induced Pressure 4. Tiredness / Fatigue 5. Inadequate Communication 6. Unfamiliar Jobs / Poor Training 7. Ambiguity 8. Highly Routine Procedures / Complacency

6 What Happens When We Don t Follow Procedures? INDIVIDUAL Bad habits develop. TEAMS negative norms or groupness develop. WE HAVE A Followed later by acceptance of the group. BREAKDOWN IN Normalization of Deviation becomes accepted. DISCIPLINE!! Lack of awareness of Behavior Creep. Accidents and mishaps with immediate result immediate feedback. Lucy under Pressure

7 System design Norm begins Drifting from an Effective Performance System When we violate a procedure and Effects of the Normalization of Deviance Baseline performance nothing bad happens, we perceive Practical drift the action to be acceptable. - Time saving - Looks good to management - Looks efficient - Saves money

8 WHEN NEGATIVE NORMS BECOME ACCEPTED AND PRACTICED, THESE NEGATIVE PRACTICES BECOME THE NEW STANDARD. EXAMPLE: When a step is skipped (short-cut) and there is no immediate negative impact (may even be a positive impact such as cost and time savings), this new method may be looked upon as a positive step. The group does not see the danger. However the chance for errors increase! AA DC-10 at Chicago, May 25, (Mx) Gulfstream IV at Hanscom Field near Boston, May 31, (Ops)

9 What Influences Our Taking Behavior? Responsibility

10 Social Influence How behavior is influenced by the social environment and the presence of other people. Ø Obedience to authority Ø Team Conformity

11 Two Classic Studies in Taking Responsibility A B Standard1 2 3 Dr. Milgram - Obedience to Authority Experiments Dr. Asch - Conformance to Group Experiments

12 Milgram - Obedience to Authority Obedience Compliance of person is due to perceived authority of the requester. A request from an authority is seen as a command. Milgram did his first experiment in He was interested in unquestioning obedience to orders, because I was just following orders was the defense used by Nazi war criminals. Wanted to see if the average U. S. citizen would refuse to do something where they felt that they were hurting another person. Recruited 40 men for a study of memory through a newspaper advertisement. Each person was paid $4.00 to participate.

13 Milgram Study Basic study procedure: Experimenter (Dr. Milgram), Student (working with Dr. Milgram), and Teacher. Teacher helps Experimenter strap Student into chair and attach electrode to arm. Student expresses concern over his heart condition. Experimenter gives Teacher a 15 volt shock. Dr. Milgram had a colleague play the role of Student The Student, working with Dr. Milgram, acted like he was receiving the electrical shocks. Intimidating shock generator ü volts Slight ü volts Moderate ü Up to.. ü volts XXX

14 Milgram Study Student actually set up a tape recorder integrated with the electro-shock generator. 120v Ugh! Hey this really hurts. Tape recorder plays prerecorded sounds for each shock level in which the Student protests more and more as the shock level increases. At 150 volts, the Student starts banging on the wall as the tape recorder plays his protests. 150v 300v 315v Ugh! Experimenter! That s all. Get me out of here. I told you I had heart trouble. My heart s starting to bother me now. (Banging on wall.) (agonized scream) I absolutely refuse to answer any more. Get me out of here. You can t hold me here. Get me out. (Banging on wall.) No longer any noise coming from Student, as if he died from a heart attack.

15 Experimenter Asks for Total Obedience If at any time the Teacher wanted to stop, the Experimenter gave him verbal responses in this order: 1. Please continue. 2. The experiment requires that you continue. 3. It is absolutely essential that you continue. 4. You have no other choice, you must go on. If the Teacher then still wished to stop, the experiment was halted. Otherwise, the experiment continued until the Teacher had given the maximum 450-volt shock three times in succession.

16 What Was the Predicted Behavior? Before the study, Milgram Asked 140 senior Psychology majors, who estimated 1.2% on average would go to the highest shock level. Informally polled his colleagues, who also believed that very few subjects would go to the highest shock level. 40 Psychiatrists at the medical school believed that By the tenth shock, when the Learner demands to be freed, most Teachers would stop. By the 300 volt shock level, when the victim refuses to answer, only 3.73% on average would continue. Only a little over 0.1% (1 in 1000) would continue to 450 volts.

17 What Was Teacher s Actual Behavior? What percentage of Most felt uncomfortable giving the shock. Every teachers paused went and questioned to the the experimenter. maximum voltage as Some said they would refund the $4.00. Throughout, every commanded? teacher displayed varying degrees of tension and stress. They were sweating, trembling, stuttering, biting their lips, groaning, digging their fingernails into their skin, and some had nervous laughing fits.

18 Results of the Study A majority of people will probably do what their management tells them to do, even if they do not feel comfortable doing it. You want a paycheck? 65%

19 Group Conformity Dr. Asch was interested in whether a person would conform to the beliefs of the group / team. Go along with the crowd. Conformity = Adopting attitudes or behaviors of others because of group/team pressure to do so. The pressure can be real or imagined. Main reason for conformity to be accepted as part of the group/team.

20 Asch Study Team Acceptance Study Eight people seated around a table Cards with lines All but the eighth person worked with Dr. Asch Dr. Asch Working with Dr. Asch Not working with Dr. Asch the subject of the experiment

21 Asch Study Task The task was to pick the line that matched the standard line. First person 1 told to pick the wrong line 12 out of 18 times (on the first two trials, he picked the correct answer, but on trial 3 he gave the wrong answer). Then people through 7 repeated the answer given by 1. 2 Question: What would the last person 8 (subject) say? Standard line Comparison lines

22 Asch Study Results In a team, we tend to feel less Asch found that responsible. 75% of subjects conformed to give at least one wrong answer. Only Someone 25% always else gave will the correct do it. answer. The whole team agreed. Nobody saw me do it it Group/team pressure to conform also called peer pressure. could be anyone.

23 Why Subjects Did Conform All subjects were interviewed after the study. The 75% of the subjects who did conform on at least one trial: Distortion of perception conformed on almost every trial and believed that the others incorrect answers were actually correct (small number of non conformers). Distortion of judgment got to the point where they believed that they must be wrong and the others must be right, so gave the same answer. They lacked confidence and were very doubtful (majority of conformers). Distortion of action knew what the correct answer was, but conformed with the majority group simply because they did not want to seem inferior.

24 What is the Message from the Asch Study? Co-workers have a large influence over others attitudes and behavior. PEER PRESSURE IS VERY STRONG!

25 So, Why Do We See Unprofessional Behavior? Supervisor Behavior displays starts to negative stray from punishment the professional for carrying standards out the for professional various reasons behavior. (uncomfortable, time constraints, equipment unavailable). What Supervisor do you mean (or person you don t responsible feel qualified for upholding to do the the job? policies/processes/procedures) You re trained. You re certified. does Go not out intervene. there and do that work. You want to keep your job, don t you? A behavior uncorrected is a behavior condoned. Hey, you don t have time to go get the maintenance manual. Unprofessional You want behavior to get that becomes airplane the out norm. on time, don t you? Existing Time is workers my money! put peer pressure on new hires to conform to these behaviors.

26 Then How Do We Move Back to Professional Individual Behaviors? What you should do Know the Dirty Dozen and how they affect your individual performance. Maintain a strong personal discipline ü 1. Not accepting that rules must sometimes be bent to get the job It s all about good done; ü 2. Controlling the feeling that you have the ability and experience to do the without utilizing SOPs; ü 3. Communicate concerns by being assertive (don t let teamwork LEADERSHIP and and pressure lead you astray to develop groupness ) rejecting short-cuts; strong personal ü 4. Recognize complacency when Normalization of Deviation becomes a BAD habit (Pressure / Stress / fatigue) DISCIPLINE!!!

27 Summary Always Aviation professionals ask yourself are when expected considering to act in a not to professional follow a proper manner. procedures Unprofessional.. behavior happens because Behavior drifts away from professional behaviors due to issues What like time might constraints, happen no equipment, if..? and because The drift is not immediately noticed. Management and co-workers don t enforce the professional behaviors or pressure others to engage Then ask yourself what a jury in professional behaviors or... might Management decide pressuresif staff something to engage unprofessional went behaviors and reinforces unprofessional behavior. Then there is peer pressure wrong. to conform to existing unprofessional behaviors.

28 First you find yourself overlooking small infractions that you would have corrected on the spot in the past. Soon, you are a participant in these infractions. After all, you say, everyone is doing it. All too soon you find yourself trapped. You no longer can stand on a favorite principle because you have strayed from it. Finding no way out, you begin to rationalize, and then you are hooked. The important fact is, the men who travel the path outlined above have misused the very basic quality and characteristic expected of a professional They have compromised their integrity. Admiral Arleigh Burke, USN Thank You for your participation